Fulton Montgomery Regional Chamber Energy Alliance

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Fulton Montgomery Regional Chamber Energy AllianceSM A program of the Fulton Montgomery Regional Chamber of Commerce

Participation Authorization Yes, we are interested in procuring energy supplies and services through the Fulton Montgomery Regional Chamber Energy AllianceSM (“Alliance”). In signing below, we are indicating our consent and authorization: 1. For our electric and/or gas utilities to provide data (which will be kept confidential) about our energy usage and costs that may be requested by the Alliance, its consultants (EnergyNext, Inc.), and/or selected suppliers; 2. For the Alliance or its consultants to include our name listed as a potential power purchaser for the purposes of supporting competitive procurements to be issued by the Alliance or its consultants to providers of energy supplies and service. NOTE: The execution of this Participation Authorization is NOT a commitment by this organization, nor an obligation to contract for electricity or natural gas through or in conjunction with the Alliance. No commitment or obligation will be required until a pricing offer and agreement is presented and accepted.

Organization____________________________________________________________________ DBA (if applicable)______________________________________________________________ Address _______________________________________________________________________ City ________________________________________ State __________ Zip _______________ Contact person ________________________________ Title _____________________________ Phone ______________Fax ___________________ E-mail ______________________________

Exempt from paying sales tax? YES

NO

PLEASE ATTACH 2 MONTHS OF YOUR ELECTRIC AND/OR NATURAL GAS UTILITY BILLS. Signature _____________________________ Title _______________________ Date ________

Please return this form and utility bills to Fulton Montgomery Regional Chamber of Commerce 2 North Main Street, Gloversville, NY or Fax: 518-725-0643.